What is the diagnosis for a patient with a complex medical history, presenting with longstanding neurodevelopmental symptoms related to Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD), combined type, along with associated anxiety and episodic depressive symptoms?

Primary Diagnosis

This patient should be diagnosed with Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Type, with comorbid Generalized Anxiety Disorder and Adjustment Disorder with Depressed Mood. 1

Rationale for Primary Neurodevelopmental Diagnoses

Autism Spectrum Disorder

The patient meets full diagnostic criteria for ASD based on:

• Formal comprehensive evaluation in 2023 confirming the diagnosis 1
• Lifelong pattern of social-communication deficits including difficulty maintaining friendships beyond structured environments, limited social reciprocity, and challenges with conventional social engagement 1
• Restricted/repetitive patterns including rigid need for routines, sensory over-responsivity leading to autistic shutdowns, and difficulty with transitions 2
• Symptoms present from early development despite late formal recognition 1

ADHD, Combined Type

The patient meets DSM-5 criteria for ADHD with:

• Formal diagnosis last month following extended assessment 3
• Documented symptoms before age 12 (early academic difficulties with attention and auditory processing despite giftedness) 3
• Persistent inattention, impulsivity, and disorganization across multiple settings (home, work, academic) 3
• Significant functional impairment in occupational and daily living domains 3
• Executive functioning deficits that have been chronic and pervasive 3

The elimination of mutual exclusion between ASD and ADHD in DSM-5 allows both diagnoses, and approximately 50% of individuals with ASD also meet criteria for ADHD. 1, 4

Comorbid Psychiatric Conditions

Generalized Anxiety Disorder

• Chronic anxiety symptoms requiring PRN benzodiazepine use 3
• Anxiety-related blood pressure elevations necessitating propranolol 3
• Functional impairment from anxiety symptoms 3
• Anxiety disorders are particularly common in ASD, with more than 90% of individuals with autism having at least one comorbid condition 2, 1

Adjustment Disorder with Depressed Mood

Rather than Major Depressive Disorder, the episodic depressive symptoms are better conceptualized as:

• Reactive to identifiable stressors (occupational burnout, unresolved grief from relative's death, social isolation) 3
• Not meeting full criteria for major depression based on the presentation 3
• The previous teenage hospitalization was likely related to autistic shutdown and overwhelming demands rather than true suicidal intent, as the patient now recognizes 2

Critical distinction: The functional impairment is primarily driven by untreated neurodevelopmental symptoms rather than a primary mood disorder, as correctly identified in the assessment. 3

Diagnostic Considerations and Pitfalls

Why Not Primary Depression?

• Multiple failed antidepressant trials without benefit 3
• GeneSight testing indicating poor antidepressant responsiveness 3
• Around 10% of adults with recurrent depression/anxiety have ADHD, and treatment of depression/anxiety will likely be inadequate without addressing the underlying ADHD 3
• The patient's insight that symptoms are neurodevelopmental rather than mood-based is clinically astute 3

Ruling Out Psychotic Features

The patient does not exhibit psychotic symptoms. 2

• No hallucinations, delusions, or loss of reality testing 2
• Autistic shutdowns represent sensory/emotional overwhelm with maintained insight, not psychotic episodes 2
• Florid delusions and hallucinations are rarely seen in autism, and when present, they are transitory rather than sustained 2

Addressing Diagnostic Overshadowing

A critical pitfall to avoid is diagnostic overshadowing—attributing all symptoms to the neurodevelopmental disorders without evaluating treatable comorbid conditions. 5

• Up to 70% of youth with ASD have psychiatric comorbidities that require separate treatment 5
• The anxiety and adjustment disorder require specific intervention beyond treating the core neurodevelopmental symptoms 5

Severity Specifiers and Functional Impact

ASD Severity

Based on the presentation, this appears to be Level 1 (requiring support) given:

• Ability to work in professional role (though with significant burnout) 1
• Capacity to engage in weekly psychotherapy 1
• Independent living skills 1
• However, significant support needs for social communication and managing transitions 1

ADHD Severity

Moderate to severe based on:

• Profound occupational impairment leading to leave of absence 3
• Inability to maintain daily routines and executive functioning 3
• Persistent symptoms despite attempted interventions 3

Additional Diagnostic Codes

Complicated Grief

• Unresolved grief three years post-loss with minimal family support 3
• Unable to attend cremation, no family acknowledgment of loss 3
• This warrants specific trauma-focused intervention 3

Occupational Burnout (Z56.6)

• Severe burnout in emotionally demanding role 3
• Inability to recover during time off 3
• This is a V-code/Z-code rather than psychiatric diagnosis but critical to treatment planning 3

Treatment Implications of This Diagnostic Formulation

The diagnostic formulation directly informs treatment priorities:

1. ADHD requires immediate pharmacological intervention as the patient correctly identifies 3

   • Stimulant medication trial is indicated despite previous non-stimulant failures 1, 4
   • Methylphenidate has shown 49% response rate in ASD+ADHD populations 1, 4
   • Effects may be less robust than in primary ADHD but still clinically meaningful 4

2. Anxiety management requires both pharmacological and behavioral approaches 5

   • Continue propranolol for autonomic symptoms 3
   • Minimize benzodiazepine use due to dependence risk 3
   • Modified CBT specifically adapted for ASD 5

3. Avoid further antidepressant trials given multiple failures and pharmacogenomic testing 3

4. Behavioral interventions must be ASD-informed 5

   • Structured routines and visual schedules 5
   • Explicit teaching of coping strategies rather than assuming intuitive development 5
   • Functional behavioral assessment for shutdown triggers 5

5. Trauma-focused therapy for complicated grief once stabilization achieved 3

Summary Diagnostic Statement

Primary Diagnoses:

• Autism Spectrum Disorder, Level 1 (requiring support) 1
• Attention-Deficit/Hyperactivity Disorder, Combined Type, Moderate to Severe 3, 1

Comorbid Psychiatric Diagnoses:

• Generalized Anxiety Disorder 3, 1
• Adjustment Disorder with Depressed Mood 3
• Complicated Grief (uncoded but clinically significant) 3

Psychosocial Stressors:

• Occupational burnout (Z56.6) 3
• Limited social support 3
• Unresolved family conflict 3

This formulation prioritizes the neurodevelopmental foundation while acknowledging treatable comorbidities, avoiding the common pitfall of attributing all symptoms to mood disorder when the primary drivers are ASD and ADHD. 3, 5